Structuring agency Examining healthcare management in the USA and Australia using organizational theory Julianne Payne and Jeffrey Leiter Department of Sociology and Anthropology, North Carolina State University, Raleigh, North Carolina, USA Abstract Purpose – Since the 1970s, the healthcare industry has undergone significant changes. Using neo-institutional and resource dependency theories, the purpose of this paper is to explore how managers perceive constraint and enact agency amidst these historic challenges – perhaps most significantly, declining funding and increasing regulation. Design/methodology/approach – The data come from ten interviews with healthcare managers, spanning for-profit, non-profit, and government legal forms and hospital and nursing home sub-industries in both Queensland, Australia and North Carolina, USA. The authors look for patterns across the interviews. Findings – The paper shows that governments and umbrella “parent” organizations force managers to adhere to institutional expectations in exchange for resource investment. Managers navigate these environmental obstacles using a shared business-minded approach and competitive differentiation. Yet various interest groups – including front-line workers, physicians, and patients – challenge this paradigm, as they demand a focus on quality of care. Managers’ efforts are likewise curbed by the very resource and institutional pressures they resist. Originality/value – The authors understand changes in the healthcare industry as resulting from an increasingly powerful managerial logic, at odds with traditional professional and societal values. Interest groups are best positioned to challenge this logic. Keywords Healthcare management, Organizational theory, Neo-institutional theory, Resource dependency theory, Health care, Strategy, Australia, United States of America Paper type Research paper Introduction This paper examines managerial perceptions of organizational constraint and agency in healthcare as accountability and resource pressures mount. Though such pressures on managers appear to have become particularly acute in recent years, the organization of healthcare in the USA has been in flux for decades (Starr, 1982). In the 1960s, the period of medical professionals’ dominance gave way to a period of government intervention (Scott et al., 2000), but resources to deliver care remained plentiful and stable (Starkweather and Cook, 1983). The main environmental challenge for The current issue and full text archive of this journal is available at www.emeraldinsight.com/1477-7266.htm The authors are grateful for the suggestions they have received from Alan Hough, Mark Lyons, Nick Solebello, and Cathy Zimmer on previous drafts, and for the welcome extended to the second author by the Australian Centre for Philanthropy and Nonprofit Studies and its Director, Myles McGregor-Lowndes. The authors would also like to thank two anonymous reviewers and the Editor for their thoughtful feedback. An earlier version of this paper was presented at the 8th International Conference of the International Society for Third-Sector Research (ISTR), Barcelona, July 9, 2008. JHOM 27,1 106 Journal of Health Organization and Management Vol. 27 No. 1, 2013 pp. 106-126 q Emerald Group Publishing Limited 1477-7266 DOI 10.1108/14777261311311825